Postremission therapy in adults with acute myeloid leukemia

A patient with acute myeloid leukemia (AML) who has achieved remission after induction chemotherapy still harbors 10(9) to 10(10), albeit undetectable, leukemic cells. Optimally, postremission therapy safely reduces the leukemic burden to a level compatible with long-term disease-free survival. Although older adults fare poorly with intensive postremission therapy, young and middle-aged adults can receive either chemotherapy based on high-dose cytarabine or myeloablative therapy in preparation for autologous or, if a histocompatible donor is available, allogeneic stem cell rescue. The rationale for each approach, the prospective trials comparing the various options, and a suggested strategy for choosing among them is presented. Although cytogenetic category at diagnosis is the most important prognostic factor, this feature remains an imperfect guide to postremission therapy. An informal consensus has arisen in favor of chemotherapy for patients with good prognosis and allogeneic transplant for those whose AML displays an adverse karyotype. For the intermediate group, an individualized decision is required and any of the three options is reasonable. Because the relapse rate is so high, new therapies for AML, such as signaling and immunotherapeutic approaches, are the focus of active investigation.